False positive

My daughter wanted to know about false-positive tests this week. She's a fan of the TV medical drama, House, so I caught a bit of it while I was doing the dishes (you'll have to take my word for it).

An oncologist had to break some disturbing news to a patient. Of course, there was a twist.

The man had been diagnosed with terminal lung cancer, but it turned out that the test was incorrect, i.e false-positive. He didn't have cancer at all. The oncologist expected that the man would be thrilled to hear the news. He wasn't.

The oncologist couldn't understand why the man was upset. Surely he should be overjoyed at having his life sentence lifted!

The problem was that the man had already acted on the false report. He had told his friends the bad news. He had sold his house and spent the money on a trip to Europe. While he was happy that he didn't have cancer, he was not pleased with the profound effect this false alarm had on his life.

A similar situation comes up very commonly in urology practice. Men are often tested for prostate cancer using prostate-specific antigen (PSA). Well, at least they think they're being tested for prostate cancer. The PSA blood test doesn't actually give a yes-or-no answer to this question. It just tells us how suspicious we should be and whether further testing is warranted. The higher the PSA level, the greater the likelihood that prostate cancer is present.

But there's a twist here, too.

Benign prostate enlargement - very common in men over age 50 - also causes the PSA level to rise. In fact, when the PSA is mildly elevated (for example, between 4 and 10), it's more likely that the elevation is due to benign disease rather than cancer, in a 2:1 ratio. That's a lot of false-positives.

The abnormal PSA level leads to further testing, usually a prostate biopsy. This involves inserting a probe into the rectum and using a needle to take samples of the prostate. It's uncomfortable and carries some risk of complications. Also, men with abnormal PSA levels suffer anxiety about the possible cancer diagnosis.

When there is no cancer present (i.e. the PSA level was up because of benign prostate enlargement), the man goes through a needless biopsy and worry. Yet, when I call men about their negative biopsy results, they universally say "Whew, that's good news."

I sometimes wonder why they don't react like the patient on House: "You mean I went through all that worry and that biopsy done for nothing? I never had a problem in the first place. If I hadn't had that PSA test done, I could have been spared all of this. That test was a false alarm!"

When a false-positive test comes back, it means we've taken a healthy person (well, at least, they don't have that particular disease) and put them through stress and further testing that is of no value to them. Many people rationalize this with the old "Better safe than sorry" argument.

Of course, it's up to each man to decide whether he wants to take the chance of having a false-positive result. That means he should be informed of the risks and benefits of PSA screening before being tested. My experience is that most men haven't been informed before testing. Many of them aren't even aware the test was done (usually as part of "routine blood work") until they're called with the abnormal result.

"Better safe than sorry" only holds true if the patient has had the chance to consider how much "sorry" they're willing to accept to be "safe".

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Outside the RateMDs box

A member of my spy network reported overhearing some first-year medical students talking about their clinical shadowing.

Medical students are required to spend time with clinicians in order to get a broad exposure to the various medical disciplines. These students were planning to surf RateMDs to check out potential mentors for shadowing!

Brilliant. (Really.)

Most of the comments on RateMDs pertain to the physician's affability and communication skills. When patients are unhappy with a physician, it almost always means that communication has been poor.

As such, if physicians are rated highly on RateMDs, they're likely to be pleasant to spend time with under other circumstances, i.e. clinical shadowing.

Plus, they'll be good role-models. That counts for something, too.

Hey, you kids! How about a mash-up that combines the list of College of Medicine-approved clinicians with their RateMDs profiles? It'd save you time and probably make for some entertaining reading. Let me know when you've whipped it up.

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Holidays on-line

Google does it again! We just moved our office holiday calendar on-line and it is great!

Until this week, all the docs in our practice requested and recorded holidays on a paper calendar. That meant that we had to be at the office to check the calendar and write in our requests.

Now, the paper calendar has been tranferred to Google Calender. Each doc has his/her own holiday calendar, which Google merges onto a master calendar.

My wife and I just decided on a trip we'd like to take. Rather than waiting until I'm back at the office on Monday to book the days off work, I just checked the calendar on-line and submitted my requests by email.

We can also clearly see how many people are away during any given week, in order to avoid leaving the practice short-handed. At year end, tallying up the number of holidays taken will be easier, as each physician's calendar can be reviewed individually.

Easier holiday planning brought to you by Google.

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Enough with the miracles already!

Physicians, please take this oath:

"When a patient makes a recovery that seemingly defies the odds, I will celebrate the event, but will refrain from invoking supernatural explanations."

Translation: Stop calling stuff "miracles"!

Our local paper recently carried the story of a woman who recovered from an overwhelming critical illness. She reported that the doctors involved called it "a miracle" that she survived.

When physicians resort to the "miracle cure" hypothesis, what they're really saying is:

Your outcome has been much better than I predicted. I don't see a flaw in my reasoning, acumen or experience. Ergo, it's beyond rational explanation. A miracle!

Why not try "I'm very pleased that you have recovered. My prediction was incorrect. I'll certainly learn from this experience."

Let's be honest about our cognitive shortcomings.

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Re: WWWTP VIII - links fixed

Sorry if you had trouble following the links to the CMAJ letters in "What's wrong with this picture? - VIII". I've repaired the link so it connects to the Dec. 4, 2007 letters to editor.

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What's wrong with this picture? - X

Today's WWWTP is a new post, Darwin's Cystoscope, at Adventures in Advanced Access.

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Information please, doctor

I just finished my morning office and I have to get this off my chest:

I saw 2 elderly men, whose referring physician's letter essentially said:

"This man has multiple medical problems..."

... with no list of the problems! So, I had to find out about all the problems myself.

Also this week, I heard from a patient's family member who wondered why the patient was repeatedly asked the same questions by each physician/nurse who saw him:

"Is there no method of charting that follows patients to reduce this issue and frustration for both staff and patients?"

Bingo! Electronic health records will certainly help with this, but in the meantime, would all the referring physicians out there please help out and send your patient's past medical history details?!

We've developed a checklist for patients being referred for microhematuria. Maybe we need a checklist for all patients that says "Please include the reason for referral, patient's past medical history, list of medications and allergies". Is it really necessary to give that reminder? If I were a referring physician and received such a checklist, I think I'd be insulted. "Well, duh, of course I send along that information. I don't need to be reminded."

OK, I feel better now. On with the day.

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Whoa to checklists?

Atul Gawande's at it again. Check out this NY Times op-ed about how bureaucracy shut down a successful program that reduced central line sepsis.

Excellent clinical care is no longer possible without doctors and nurses routinely using checklists and other organizational strategies and studying their results.

- Gawande

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Mmmm... Checklists!

More on the yummy goodness of checklists (c/o Atul Gawande).

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New Year's Resolution

Old joke:

You're working class if your name is on your shirt.
You're middle class if your name is on your desk.
You're upper class if your name is on the building.

So what does this picture mean?



This the CEO of the Saskatchewan's largest employer - Saskatoon Health Region. And she's wearing a name tag.

It's not just for this photo-op, either. I've seen her around several times over the last month and she was wearing the name tag each time. What's up?

When I spent some time at Calgary Foothills Hospital last spring, I noticed that all the staff wore name tags. Including physicians. I found that unusual because most physicians in SHR don't wear name tags in the hospital.

Granted, most residents do wear their name tags, but it's unusual to see staff physicians wearing them. A notable exception would be the ones who wear lab coats at work. In those cases, they leave the name tag clipped to their pocket and don't have to worry about moving it between different items of clothing. (It also means they don't change/launder their lab coats very often, but that's a whole different subject...)

I think physicians don't see a need to wear a name tag. Most of us are well known to the staff in the hospitals that we frequent. A name tag would be a nuisance to cart around, especially if you're changing in and out of scrubs several times a day.

However, there may be some good reasons to wear one:

Collegiality - if other staff are required to wear name tags in hospitals, do physicians deserve an exemption because we're somehow... exempt? (Trying to avoid using "superior" here.)

Courtesy - new staff, or staff on wards I don't visit often, may forget/not know my name. Same for patients and their families, if we've only met recently and/or briefly.

Security/Patient privacy - This is the big one. I can probably walk onto any hospital ward (where I'm not well known) in the city, flip open any patient's chart and start reading. A layperson could probably get away with the same thing if they were neatly dressed (or in scrubs!) and had an air of confidence. I think it would be rare to be challenged.

So why does our CEO wear a name tag? She's not involved in clinical care. She's one of the most recognized people in the health region.

Could she be modelling appropriate behavior? That would be very sneaky.

Anyway, here's my New Year resolution: I'm going to start wearing my name tag at the hospital. If you see me at the hospital without this -



- call me on it.

And mention that you saw it on Plain Brown Wrapper!

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New Division of Urology website/blog

The new year sees the launch of a new Saskatoon Division of Urology blog. But you can't see it.

Sorry to be a tease about this, but it's intended for internal communication among our urologists.

I see it as a repository for meeting records, schedules of grand rounds and journal club, call schedules, etc.

As with all new things, the challenge is in selling it. I'll load up the blog with stuff like links to the health region's digital image/X-ray archive, our call schedule, and clinical guidelines. We'll see if the urologists think it's worthwhile.

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